Preventing Gun Deaths: A Public health Perspective

1. Preventing Gun Deaths: A Public health Perspective John Lennon December 8, 1980, Shot at close range with 4 hollow-point bullets from a Charter Arms Undercover .38 Special. Steve Miles, MD Center for Bioethics, University of Minnesota 34,000 persons die per year in US of Gun Deaths Gun Suicide October 2017 update

2. Disclosures and Objectives • Steven Miles prepared these slides and has no conflicts of interests to declare. No off-label uses are discussed. • Attendees will be able understand and be able to apply knowledge about the relationship between access to a firearm and suicide, homicide, domestic homicide. • Attendees will understand be able to understand the possible effects on public health of various public policies with regard to guns. • Attendees will understand and be able to advise patients and families of the effect of having a gun for self defense.

3. a public Health Approach • Study gun related injuries to examine the gun user, the victim, the gun, and the setting. • Identify factors associated with more / less risk of injury or death. • Risk factors are not “causes.” • Risk factors do not predict morbidity in a particular case. • Use lessons from other public health campaigns (e.g. tobacco, automobile safety, etc.) • Develop, demonstrate, implement and monitor morbidity prevention strategies. J Pub Hlth Pol 2001; 22:381-402.

4. 34,000 persons die per year in US of Gun DeathsGun Homicides and Accidental death rates are Declining Ann Rev Pub Hlth 2015;36:5-19

5. Violent deaths in US K-12 are Flat 2015 US Department of Education Sandy Hook 2012 was 20 deaths

6. College Murders-Oct 9, 2015 45 American Journal of Public Health | August 2015, Vol 105, No. 8 20 2015 2002 2012 US Dept of Education

7. NRA Blocks Research Nat Instit Alcohol Abuse and Alcoholism in Am J Pub Health shows  risk to assaulted gun carrier. 2 CDC N Engl J Med: guns in home associated with  homicide & suicide. Sandy Hook 2009 2012 1992, 93. 2014,5 1996 2013 2011 NRA successfully lobbies to instruct CDC: "None of the funds . . . may be used to advocate or promote gun control.” Gun research  96%. NRA successfully lobbies to bar Bureau of Alcohol, Tobacco, Firearms and Explosives from using gun data to make conclusions about gun crimes. CDC research ban extended to Dept Health and Human Services agencies, (e.g. NIH). GOP house block $10 M for gun violence research. 1976Consumer Product Safety Commission is barred from creating gun safety standards.

8. “Our concern is not with legitimate medical science.” “Our concern is they were promoting the idea that gun ownership was a disease that needed to be eradicated.” "I'm Sorry, but a Gun Is Not a Disease" Internet pornography: a "public health crisis” - Draft GOP Platform 2016

9. More GUN Households: More Gun Deaths. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.1286

10. Gun Deaths • 33,636 Deaths / year. • 75,000 ER visits / year.

11. 41,000 Total Suicides Suicide

12. Suicide and Gun Ownership Rate of Non-Gun suicides Rate of Gun suicides Am J Epi 2013;178:946-55. Also Inj Prevent 2015;21(e1):e116-9. Rate of All suicides Gun Ownership % of households

13. Suicide in largest metro Areas Total Firearm Non-gun Inj Prev 2015;21:e116–e119.

14. Gun Suicide: Older, Male • US Suicide: • 7th cause of death for men • 15th cause of death for women. • Guns are used in 21,000 of 41,000 (51%) suicides Access to firearm increases risk of suicide by 3.24 (CI 2.4-4.4) • Ann Intern Med. 2014;160(2):101-10. Meta-analysis 14 studies (12 US, 1 NZ, 1 Ire) When there are guns in the home, womens’ risk of suicide increased 5 fold. • Inj Prev. 2006 June; 12(3): 178–182. Multivariate population study, US.

15. higher risk of suicide in Gun Owning household not explained by More Mental Illness In the households. • People in homes with guns are no more likely to have anxiety, mood disorders, substance dependence, or suicidal ideation or planning. • Having made a suicide attempt over the past year was the only mental health factor more common in people who lived in a home without firearms. • Injury Prevention. 15(3):183-7, 2009 Jun. Household survey of 9282 adults. Multivariate logistic regression analyses controlled for age, sex, race/ethnicity, educational attainment and poverty.

16. Suicide After Gun Purchase: • Suicide leading cause of death of handgun buyer during 1st year after purchase. • N Engl J Med 1999; 341:1583-9. • Background check and/or delayinggun pickup 2-7d …...suicide rate 11%. • ProcNat AcadSci 2017 doi: 10.1073/pnas.1619896114, 1970-2014, allstates Months after Purchase

17. Teen Suicide: Accessnot Impulse • 80% of teen suicides are at home. • Handguns used in most teen suicides. • A home with a handgun is 10 times more likely to have a teen suicide. Most guns owned by parents. • Teen gun suicide trys are 80-90% lethal. • Youth Suicide by Firearms Task Force. http://www.pbs.org/thesilentepidemic/riskfactors/guns.html • Suicide & Life-Threatening Behav. 2010;40:609-11. • Children committing gun suicide do not have more suicide risk factors (e.g., suicidal thoughts). • Suicide and Life Threatening Behav. 2004; 34:36-43. CDC 2015 Adolescents with suicide risk factors are as likely to report in-home firearm access as those without risk factors. AMA Psychiatry 2015;72:152-9.

18. When Guns leave Households: Fewer People, especially teens, Suicide. When there are guns in the home, womens’ risk of suicide increased 5 fold. Each 10% decline in percent of homes with children andguns, is associated with 8.3% drop in child firearm suicide. • Inj Prev. 2006 June; 12(3): 178–182. Multivariate population study, US. • See also: J Trauma 2007;62:1029-35. NB: Studies suggest that handguns are a greater risk than long guns and that guns stored unlocked are a greater risk than guns stored locked.

19. Prevalence of Guns and Prevalence of Gun Suicide. Fred Roff, Pres. Colt Firearms Data compiled by Gunpolicy.org Gun possession is per 100 left axis. Gun suicide are /100,000 persons on right axis.

20. Bottom Line: Suicide • Suicide is 2/3rds of gun deaths. • The biggest risk factor for suicide by gun is having a gun in the house. • The availability of a gun increases the lethality of a suicide attempt.

21. Homicide

22. Association between Household Gun-Ownership and Homicide rates. States with higher levels of household gun ownership had higher rates of firearm and overall homicide.  There is no association between gun prevalence and non-firearm homicide. SocSci & Med 2007 64;656 – 64., Multivariate analysis for rates of aggravated assault, robbery, unemployment, urbanization, alcohol consumption, and resource deprivation (e.g., poverty), genders and all age groups.

23. Homicide Methods-2014. 16,121 Homicides 11,208 gun homicides (69%) Bureau of Justice http://bjs.gov/content/pub/pdf/htius.pdf

24. Association between Household Gun-Ownership and Homicide rates. Access to gun increases risk of • Homicideby 2.0 (Odds Ratio 1.6-3.0) • Suicideby 3.24 (OR 2.4-4.4) • Ann Intern Med. 2014;160(2):101-10. Meta-analysis .9% increase in homicide for every 1% increase in home gun ownership after controlling for • violent crime rates, • non violent crime rates. • incarceration rates, • income inequality, • race. • Am J Public health 2013;103:2098-2106

25. Guns and Intimate Murder Gun owners are 8 times more likely to threatentheir partners with a gun than non-gun owners.  • threaten to shoot them • threaten to shoot a pet or person the victim cares about, • cleaning, holding or loading a gun during an argument, • shooting a gun during an argument. • J Am Med Women Assn, 2005; 60:62-8. 8,000+ men in a batterer intervention program in MA, 1999-2003.  See also  Evaluation Review. 2006; 30:283-95.

26. Guns and Intimate Murder • Gun intimate assaults: 12 times more likely to result in death than non-gun assaults. • Gun in the home: 3 times more likely a person will be murdered by a family member or intimate partner. • http://www.silentwitness.net/sub/violences.htm 1,100

27. Prevalence of Guns and Prevalence of Gun Homicide. Data compiled by Gunpolicy.org Gun possession is per 100 left axis. Gun homicide are /100,000 persons on right axis.

28. Relative Homicide rate vs Per Capita Income in High Income countries USA Can Lux Data from World Bank, 2007, Small Arms Survey

29. Bottom Line: Homicide • Community homicide rate is highly associated with the prevalence of guns in homes. • Guns in homes the most powerful predictor of domestic intimate violence becoming a homicide. • As in suicide, the availability of a gun potentiates the lethality of homicidal impulse.

30. 14,675 wounded but survive (1/5 under 19 years old). NCIPC GUN Accidents

31. Gun Accidents • Fatal gun accidents are 1% of lethal home accidents(poisonings 43%, falls 34%, burns 9%). • BUT: 14,675 woundedbut survive (1/5 under 19 years old). NCIPC • AND: Preventable • Accidental lethal shootings 8 X more common in the 4 states with the most guns compared to the 4 states with the fewest guns • Acc Anal Prev 2001;33: 477-84. • Adults with a gun in the home have a 4 fold higher risk of dying of an accidental gunshot. • AccAnal Prev35(2003)711-716

32. 350 160 Children (<14 Years) Deaths per year Children

33. Relative Risk of Gun Homicide, Suicide and lethal Accident for 5 to 14 year olds in High and Low Gun states J Trauma2002; 52:267-75. High Gun States are LA, AL, MS, ARK, WV Low Gun States are HI, MA, RI, NY, DEL 1

34. Gun deaths for Children • 5 to 14 year olds: US unintentional gun death rate 11 times higher than combined rates of 22 other high-income countries. • J Trauma 2011;70:238-43. • 0 to 4 year olds: gun deaths 17 times more common in high gun states than low gun states. • 5 to 14 year olds: gun deaths are 14 more common in high gun states than low gun states. • Acc Anal Prevent 2001;33: 477-84

35. Bottom Line: Child GUN Deaths • Guns in the home are the most powerful predictor of lethal gun accidents, suicides, and homicides of children.

36. “The only way to stop a bad guy with a gun is with a good guy with a gun,” NRA Executive Vice President Wayne LaPierre. Kokapo—a rara avis Guns for Self Defense

37. It is not 2.55 million Defensive Gun Uses / year! Cato Institute. Tough Targets. 2012. 8 years of news clippings. • 277 reports where intend-ed victim disarmed criminal. • 25 armed rape attack victims got upper hand. • 65 armed carjack victims prevailed. • 11 out of 4,699 where criminal took gun away from a defender. Bureau of Justice http://bjs.gov/content/pub/pdf/htius.pdf

38. Self-Defensive Gun USE (SDGU) 127 of 14,000 (.9%) personal contact crimes, intended victim had a gun. After any protective action, • 4.2% of unarmed victims were injured • 4.1% of armed SDGU victims were injured. P=NS. In crimes where there was an intent to steal property, • 56% of victims who took protective action lost property, • 39% of SDGU victims lost property • 35% of victims who used a weapon other than a gun lost property. • Preventive Med. 2015: Apr 21. National Crime Victimization Surveys 2007–2011. Multivariate analyses controlled for age, gender of offender and victim, if offender had a gun, urbanicity, and thirteen types of self-protective action.

39. Carrying a gun: protection in an assault? • Persons carrying a gun were 4.46 (P < .05) times more likely to be shot in an assault than those not carrying. • Among gun assaults where the victim carrying a gun had a chance to resist, this odds ratio increased to 5.45 times more likely to be shot.(P < .05). • Am J Public Health. 2009 Nov;99(11):2034-40.

40. Concealed Carry Law: Arizona Arizona Senate Bill 1108 (SB-1108) allows adult citizens to carry concealed weapons without a permit and without completion of a training course. After the law passed in 2010, • gun-related homicides 27% (RR= 1.27; 95% CI 1.02-1.58). • J Trauma Acute Care Surg 2014;76:569-74. Retrospective cohort study of 24 months before and after law.

41. How many people are Packing? Of handgun owners • 24% ([CI]21-, 26%) carried loaded handguns at least once a month. [of these, 35% (95% CI = 29%, 41%) did so daily; • 9 million adult handgun owners carry loaded handguns monthly, 3 million do so every day, • Am J Pub Health. 2017. e1–e7. doi:10.2105/AJPH.2017.304072. Nationally representative survey of adults 2015, (N = 1444) Carry any time in a month

42. Ease of Obtaining Concealed Carry Permit and Homicide Rate • Results. Shall-issue laws were significantly associated with 6.5% higher total homicide rates, 8.6% higher firearm homicide rates, and 10.6% higher handgun homicide rates, but were not significantly associated with long-gun or nonfirearm homicide. • Conclusions. Shall-issue laws are associated with significantly higher rates of total, firearm-related, and handgun-related homicide. • Am J Pub Health. October 19, 2017: e1–e7. doi:10.2105/AJPH.2017.304057)Compared homicide rates in shall-issue and may-issue states and firearm homicide rates in all 50 states 1991 to 2015. We included year and state fixed effects and numerous state-level factors in the analysis.

43. Concealed Carry Deaths763 deaths 38 states and DC, 2007-2015 Incomplete(544 incidents. 29 mass (4 or more) shootings with 139 victims) ! Legal Self Defense Accident 21 12 Suicides 223 Homicides – 442 Murder suicide 48 Police die 17 197 Convicted 63 Charges pending 4 Incompetent to stand trial 5 Under investigation Violence Policy Center Data as of 2/5/2015

44. Bottom Line: Guns for self Protection from harm. • An armed citizenry is not substantially protected from criminal injury. • Concealed carry, like high prevalence of guns, increases risks of criminal injuries in the community.

45. Kokapo—a rara avis Do Gun Control Laws Decrease Gun Deaths?

46. Public Opinion on Gun Control--Gallup Do you have a gun in your home? 60 40 Yes 20 In general, should gun laws be more strict? Yes 60 0 2010 1991 2000 2017

47. state laws associated with reduced Gun Homicides and Suicides Buyer background checks (Rel Risk .39 [95% CI 0·23–0·67]; p=0·001) Ammunition background checks (RR .18 [0·09–0·36]; p<0·0001) Identification requirement for firearms (RR .16 [0·09–0·29]; p<0·0001) • Projected national implementation of • universal background checks could reduce national firearm mortality from 10.35to 4.46 deaths per 100 000 people, • background checks for ammunition purchase could reduce to 1.99 • And firearm identification to 1.81per 100 000. Lancet 2016;387:1847-55. Multivariate adjusted, all states, homicide and suicide deaths, 25 different laws, adjusted for demographic and firearm ownership rates.

48. Handgun Purchase Waiting Periods • 17% Reduction in gun homcides • 11-17% Reduction in gun suicides. • Proc Nat AcadSci 2017 doi: 10.1073/pnas.1619896114, 1970-2014, allstates, averagewaitof 2-7 days. Notmultivariateexcept for combinationsofwaitingperiodsand background checks. See also: Am J Public Health. 2015;105:1703–09 Stricter laws lower deaths and injuries.

49. The Doctor’s Office

50. American Academy of Pediatrics (paraphrased) • Pediatricians should counsel parents to guard access to their guns inside and outside the home. • Pediatricians should ask about presence and availability of firearms …and urge parents who possess guns to prevent access to these guns by children. • Clinicians should counsel parents of all adolescents to remove guns from the home or restrict access to them. This advice should be reinforced for patients with mood disorders, substance abuse problems (including alcohol), or a history of suicide attempts.